Prior Authorization Criteria � Botulinum Toxin Policy Number: C8755-A CRITERIA EFFECTIVE DATES: ORIGINAL EFFECTIVE DATE LAST REVIEWED DATE NEXT REVIEW DATE 03/2016 01/2019 01/2020 J CODE TYPE OF CRITERIA LAST P&T APPROVAL J0585, J0586, J0587, J0588 RxPA Q1 2019 PRODUCTS AFFECTED: Botox/Botox Cosmetic (onabotulinumtoxinA), Dysport (abobotulinumtoxinA), Myobloc (rimabotulinumtoxinB) and Xeomin (incobotulinumtoxinA) DRUG CLASS: Neuromuscular Blocking Agent ROUTE OF ADMINISTRATION: Intramuscular PLACE OF SERVICE: Specialty Pharmacy, Buy and Bill AVAILABLE DOSAGE FORMS: Dysport 300Unit, Dysport 500Unit, Botox 100Unit, Botox 200Unit, Myobloc 2500Unit/0.5ML, Myobloc 500Unit/ML, Myobloc 1000Unit/2ML, Xeomin 50Unit, Xeomin 100Unit, Xeomin 200Unit FDA-APPROVED USES: Botox (onabotulinumtoxinA): Bladder muscle dysfunction - overactive, Refractory to or intolerant of anticholinergic medication, Blepharospasm, Associated with dystonia, Cervical dystonia, Prophylaxis of chronic migraine headache, Hyperhidrosis of axilla (Severe), Primary disease inadequately managed by topical agents, Incontinence due to detrusor instability, Associated with a neurologic condition, upper and lower limb spasticity, Strabismus Dysport (abobotulinumtoxinA): cervical dystonia Xeomin (incobotulinumtoxinA): cervical dystonia, blepharospasm in adults who were previously treated with onabotulinumtoxin A (Botox) Myobloc (rimabotulinumtoxinB) COMPENDIAL APPROVED OFF-LABELED USES: Hemifacial spasm,Facial spasm, Jaw-closing oromandibular dystonia, Spasmodic dysphonia (laryngeal dystonia, lingual dystonia, laryngeal spasm), Focal task-specific dystonia, Head and neck tremor, Dynamic muscle contractions in pediatric cerebral palsy, Limb spasticity, including: Heredity spastic paraplegia; Limb spasticity due to multiplesclerosis or other demyelinating diseases of the central nervous system; Spastichemiplegia; Infantile cerebral palsy, Frey's Syndrome (gustatory sweating) secondary to parotid surgery, Sialorrhea in Parkinson's Disease, Detrusor sphincter dyssynergia (lower urinary tract dysfunction) COVERAGE CRITERIA: INITIAL AUTHORIZATION DIAGNOSIS: FDA approved or compendia approved off-label uses above REQUIRED MEDICAL INFORMATION: Molina Healthcare, Inc. confidential and proprietary © 2018 This document contains confidential and proprietary information of Molina Healthcare and cannot be reproduced, distributed or printed without written permission from Molina Healthcare. This page contains prescription brand name drugs that are trademarks or registered trademarks of pharmaceutical manufacturers that are not affiliated with Molina Healthcare. Page 1 of 7 Prior Authorization Criteria � A. CHRONIC MIGRAINE HEADACHE: 1. Documented diagnosis of chronic migraines that meets international Classification of Headache Disorders (ICHD-3) diagnostic criteria for chronic migraine headache (see appendix) AND 2. The patient has a persistent history of chronic, debilitating migraine headaches with � frequent attacks on 15 or more days per month for longer than 3 months � AND � 3. There is documentation of significant functional disability (e.g., work absenteeism, multiple emergency department visits) AND 4. The member has failed or had a clinically significant adverse reaction to abortive treatment with different therapy classes, including at least three (3) of the following classes: Triptans [Imitrex® (sumatriptan), Maxalt (rizatriptan), Zomig (zolmitriptan), Amerge® (naratriptan), Axert® (almotriptan), Frova® (frovatriptan), Relpax® (eletriptan)],ergot derivatives [Cafergot® (ergotamine/caffeine), D.H.E.-45® (dihydroergotamine)], analgesics [Aspirin, acetaminophen, opioids (morphine, oxycodone)], opioid combinations [APAP/codeine, APAP hydrocodone], non-steroidal anti-inflammatory agents (NSAIDs) [Motrin® (ibuprofen), Naprosyn® (naproxen), Relafen® (nabumetone), Voltaren® (diclofenac), Orudis® (ketoprofen), Clinoril®(sulindac), Toradol® (ketorolac)], and combination products [Midrin® (isometheptene/APAP), Fiorinal® (butalbital/aspirin), Fioricet® (butalbital/APAP)] AND 5. Documentation of trial and ineffectiveness/failure after 2 months or clinical intolerance or contraindication to THREE of the following therapeutic classes: beta blockers (propranolol, timolol, atenolol, metoprolol, nadolol), antiepileptics (divalproex sodium, topiramate), antidepressants (amitriptyline, nortriptyline, venlafaxine, duloxetine), antihypertensive (verapamil, lisinopril, candesartan) B. GASTROINTESTINAL DISORDERS: 1. (a)Member has a diagnosis of esophageal schalasia and ONE of the following: High risk for complications associated with pneumatic dilation or surgical myotomy; or Failure of a prior dilation or myotomy; or Previous perforation due to pneumatic dilation; or Epiphrenic diverticulum or hiatal hernia; or Esophageal varices OR (b) Member has documentation of anal fissure refractory to conventional nonsurgical medical therapy (e.g., sitz baths, stool softeners, bulk agents, diet modifications) AND 2. Documentation of a trial/failure or absolute contraindication to topical nifedipine or topical nitroglycerin C. HYPERHIDROSIS: 1. Member has a documented diagnosis of Primary focal hyperhidrosis � AND � 2. Failure of (trial period of ≥1 month), intolerance to or unable to receive conventional medical therapy for hyperhidrosis (e.g., anti-cholinergics, anti-inflammatories) AND 3. Documentation of failure of (trial period of ≥1 month) or intolerance to Drysol (aluminum chloride) AND 4. Presence of medical complications of hyperhidrosis, including skin maceration with � secondary infection or significant functional impairment Molina Healthcare, Inc. confidential and proprietary © 2018 This document contains confidential and proprietary information of Molina Healthcare and cannot be reproduced, distributed or printed without written permission from Molina Healthcare. This page contains prescription brand name drugs that are trademarks or registered trademarks of pharmaceutical manufacturers that are not affiliated with Molina Healthcare. � Page 2 of 7 Prior Authorization Criteria � D. � MOVEMENT DISORDERS: 1. � Diagnosis of a movement or focal spastic disorder or excessive muscular contractions, including at least one of the following: Genetic torsion dystonia, Acquired torsion dystonia, Fragments of torsion dystonia, Hereditary spastic paraplegia, Multiple sclerosis or Other demyelinating diseases of central nervous system, Spastic hemiplegia, Infantile cerebral palsy, Quadriplegia and quadriparesis, Paraplegia, Diplegia of upper limbs, Monoplegia of upper and/or lower limb, Unspecified monoplegia,Trigeminal nerve disorder, Facial nerve disorder(s), Spastic entropion, Spastic ectropion, and other disorders of binocular eye movements including blepharospasm, Hemiplegia/hemiparesis, Paralysis of vocal cords or larynx, unilateral or bilateral, partial, Laryngeal spasm,Torticollis, unspecified (including cervical dystonia), Spasm of muscle (including upper and lower limb spasticity), Other musculoskeletal symptoms referable to limbs, Certain congenital musculoskeletal deformities of sternocleidomastoid muscle, Abnormal involuntary movements, Voice and resonance disorder, unspecified, Dysphonia, OR Other voice and resonance disorders AND 2. � Member has a documented failure of, intolerance to or unable to receive conventional medical therapy (e.g., physical therapy, medication) E. � SIALORRHEA: 1. � Member has a documented disability from sialorrhea due to conditions such as Parkinson’s disease or motor neuron disease AND 2. � Failure of, intolerance to or unable to receive a trial of conventional medical therapy, � including but not limited to, anticholinergics and speech therapy � F. � URINARY INCONTINENCE: 1. � Documented diagnosis of urinary incontinence due to neurogenic detrusor over activity or overactive bladder AND 2. � Documented inadequate response to or clinically significant adverse reaction to at least two anticholinergic agents (oxybutynin immediate and extended release tabs, Oxytrol patch, Gelnique gel, tolterodine immediate and extended release,Toviaz, Enablex, Vesicare, trospium immediate and extended release) AND 3. � No evidence of current urinary tract infection DURATION OF APPROVAL: Initial authorization: 24 weeks, Continuation of Therapy: 24 weeks. QUANTITY: Blepharospasm: 5 Units per site, Strabismus: 5 Units per muscle (maximum 25 units total), Cervical dystonia: 300 Units total, divided among affected muscles, Overactive bladder: 100 Units total, at least 12 weeks apart between treatments, Axillary hyperhidrosis: 50 Units per axilla, Migraines: 155 total Units (5 to 40 Units per site), Neurogenic bladder: 200 Units total, given in multiple sites, Upper Limb Spasticity: 50 Units in one site, Lower Limb Spasticity: 400 Units divided across 5 muscles, Oromandibular dystonia: 50 Units per masseter muscle and 40 Units per temporalis, Spasmodic dysphonia: 10 Units per vocal cord and 30 Units in abductor muscle, Spastic muscle contracture of pediatric cerebral palsy: 12 Units/Kg and 220 Units divided among affected muscles, Childhood myoclonus following failure of Baclofen, benzodiazepines, and antiseizuremedications: 80 Units/Kg, Chronic anal fissure: 20 Units both sides, Gustatory sweating (Frey's syndrome): 75 Units per injection, Internal anal sphincter (IAS) achalasia: 25 Units in each quadrant or 50 Units on either side of IAS, Plantar/palmar hyperhidrosis: 165 Units per palm Molina Healthcare, Inc. confidential and proprietary © 2018 This document contains confidential and